Catheter Interventions for pulmonary embolism
This is an overview of current clot removal techniques for pulmonary embolism to prevent RV failure and decompensation as well as pulmonary hypertension. Moreover, the institution’s algorithm for the treatment of the pulmonary embolism is presented.
Thanks for the review Makis.
I performed few days ago the first case at my institution inside the new PERT (Pulmonary Embolism Rescue Team)
64yo man, massive pulmonary embolism with RV failure and pulmonary hypertension in a patient with recent history of gastrointestinal bleeding in critical care unit for 2 weeks.
I did not have avalaible thrombectomy suction device as Penumbra at this moment, only angiojet and I was not sure about the use of it in the pulmonary arteries…
I gained the pulmonary arteries with a pigtail then I went with a Cook 8 F flexor curved sheath, and I performed first left pulmonary artery mechanical thrombectomy with the pigtail rotation through local arteries, also with a MPA, and the same maneuver at Right pulmonary artery. And one shoot of 150000 UI urokinasa right and 150000 left. Due to risk of bleeding I did not leave 24 fibrinolysis…but I measured immediately lower RV pressures.
One week later cardiac US showed no dilated RV and neither pulmonary hypertension.
As you mentioned there are inherent risk with this procedures but in selected cases it avoids catastrophic situations.
Fernando seems you did the right thing with the resources you have and you saved the patient! We have used Angiojet in the past but now we have adopted the newer dedicated devices. As a general rule Angiojet is avoided in the Pulmonary arteries and FDA has issued a warning due to multiple adverse events (bradycardia, arrest etc). Angiojet will soon introduce a new device for PE. Until then suction catheters and aspiration devices (Penumbra, Flowtriever etc) will lead the non-lytic therapies. Catheter lytics are otherwise a good option for those who have no contraindication and have intermediate or high risk PE.
many thanks for the presentation.
Could you mention technical steps for the procedure regarding access site, guidewires and catheters and doses of tPA as well?
Access site can be the IJ or the common femoral vein whatever you’re familiar with. If you’re targeting bilateral pulmonary arteries you can do two separate sticks or use a dual lumen sheath (10 or 12Fr). Navigate a starter (or a glide) wire into the right atrium then right ventricle then main PA. if you’re planning on using a large thrombectomy device you will need to cross with a pigtail so that you don’t go through the chordae of the tricuspid. Once in the PA do an arteriogram, transduce pressure and then navigate your catheter (glidecath) right or left depending where your target is. Exchange over a starter (or a rosen) wire to a lysis catheter (5, 6, 10 or 12 cm EKOS or standard multisidehole). Do the same for the other side and initiate tpa drip 1mg/hr per catheter for 6-12 hours. You may stop whenever you see signs of improvement (heart rate going down, less oxygen requirements etc) and pull the catheter on the bedside.
Suction thrombectomy devices are more cumbersome to use but you typically navigate them over a stiff wire. Sometimes you can just use your pigtail to fragment clot or a large catheter (Pronto) and manually aspirate)….
thank you so much